NCLEX® Review

This activity contains 15 questions.

The 64 year old male client who has undergone coronary artery bypass surgery is scheduled to have a pacemaker implanted. Because the client has a heart rate that frequently decreases to a rate that will not sustain life, the nurse anticipates that the client will demonstrate a heart rate that is

below 60.

between 61 and 70.

between 71 and 86.

between 86 and 100.

The nurse is performing a cardiac assessment on a client. In order to auscultate the client’s apical pulse, the nurse places the bell or diaphragm of the stethoscope at the

places the bell or diaphragm of the stethoscope at the left, fifth intercostals space, midclavicular line.

places the bell or diaphragm of the stethoscope at the base of the left ventricle.

palpates the left second intercostal space, midclavicular line.

multiplies the number of beats that occur in 15 seconds by 4.

Because the cardiac catheterization revealed that a client’s cardiac output was 40%, the nurse should provide which of the following instructions to the nursing assistants?

assist client to sitting position slowly

assist client with meals

keep client flat in bed

measure blood pressure while client is sitting

After taking a client, who has been in bed for seven (7) days, for a walk around the medical-surgical unit, the nursing assistant reports that the apical pulse is 110. The nurse should perform which of the following activities?

Have the client sit down immediately

No intervention is required

Provide supplemental oxygen

Ask if the client is experiencing chest pain

The client with right-sided congestive heart failure asks the nurse to explain why the heart enlarging and why it is “failing to do the job”. Which of the following statements is the best response?

“The number of cardiac cells increased which resulted in a thick, rigid wall.”

“The cardiac cells are over-stretched and now lack the ability to contract”

“Because the cardiac cells are over-stretched, the chambers cannot fill with blood.”

“The blood vessels in the heart are distended with blood resulting in a decreased flow of blood”.

Despite being immunized, a young girl is admitted to the Emergency Department demonstrating signs of tetany. Because of the skeletal muscles spasms, the mother asks the nurse if the heart will “go into spasm as well”. Which of the following is the best response?

“Let me ask the doctor.”

“That’s why we put the cardiac monitor on your daughter’s chest.”

“We’ll monitor your daughter to be certain we know immediately if that should occur.”

“The heart has its own mechanism to protect it from spasms or a state of constant contraction.”

Which of the following instructions will the nurse give to the client who is scheduled for a transesophageal echocardiograph (TEE)?

“No special preparation is needed.”

“Are you allergic to iodine of seafood?”

Do not eat or drink anything for 4 hours before the time the test is scheduled.”

“Your blood sugar will be checked just prior to the test.”

Which of the following actions is appropriate for the nurse to take when assessing the obese client’s heart sounds?

Shave the areas of the chest at which the stethoscope will be placed.

Use conductive gel on the client’s chest at the areas of auscultation.

Begin the assessment by placing the stethoscope at the apex of the heart.

Use a double stethoscope in order to detect murmurs.

Because a client is scheduled for a lipid profile (cholesterol, triglycerides, HDL, LDL), the nurse should provide which of the following instructions?

“Refrain from eating or drinking anything after midnight.”

“You may have water right up to the time of the test.”

“You should maintain a full liquid diet for 24 hours prior to the test.”

“You should have no alcohol on the evening before the test after 7:00 p.m.”

During assessment, the client asks why the nurse palpates the chest wall over the cardiac area. Which of the following is the best response?

“I am trying to determine if you have a heart murmur.”

“I am trying to determine if you have any retraction of your chest.”

“I am assessing the temperature of the skin over the chest to see if it is getting adequate circulation.”

“I am completing the part of the assessment that checks for vibrations of the chest with heartbeats.”

What is the cardiac index for a client who is 5 feet, 2 inches tall, weighs 120 pounds (54.5 kg), with a Body Surface Area (BSA) of 1.54 meters squared, and a cardiac output of 4L/min is: _____________.

2.6 L/min/m2

0.4 L/min/ m2

6.2 L/min/ m2

3.4 L/min/ m2

Because the cardiac catheterization revealed a 40% decrease in the client’s ejection fraction decreased since the last test, the nurse should place emphasis on which of the following cardiac assessments?

Cardiac rhythm

Cardiac rate

Cardiac size

Caudal edema

Two days (2) following a myocardial infarction, a client’s cardiac rhythm has several P waves without a QRS complex, the next nursing action should the following 2 steps: ______________

To create paragraphs in your essay response, type <p> at the beginning of the paragraph, and </p> at the end.

To calculate a client’s cardiac output, the nurse must obtain which of the following measures? (Select all that apply.)

cardiac index

heart rate

stroke volume

body surface area

On the figure below, identify the valves of the heart.

This question presents 4 items numbered 15.1 through 15.4. Each item is presented with a pulldown menu containing the letters A through D. For each item below, use the pull-down menu to select the letter that labels the correct part of the image.

15.1 mitral valve

15.2 aortic valve

15.3 pulmonary valve

15.4 tricuspid valve

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